Kids' mental health is still pediatricians' greatest concern, one year into pandemic

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Physician Steven Shapiro chairs the pediatrics department at Abington Hospital. He's never been a therapist. Yet a big chunk of his medical practice these days is devoted to mental health issues, far more than ever before.

"Twenty percent of the calls I take now are to put kids on more medicine for panic attacks and anxiety," said Shapiro. "It's more than you could ever believe. It has been so difficult for them, and as pediatricians, we have to recognize the downstream effects of where things are going."

Pediatricians and adolescent health experts have cautioned for months that the uncertainty and anxiety spurred by the pandemic, coupled with the lack of social contact, may have lasting effects on the mental health of children and teens, though they are significantly less likely than adults to experience serious physical illness from COVID-19.

And while declining case counts and the new vaccines may have adults feeling more optimistic, vaccines are not yet approved for those younger than 16. That means kids may still be feeling a lot of uncertainty and stress about what the rest of the year will look like for them, health experts say. Pfizer recently began vaccine trials for adolescents ages 12 to 16.

"For younger teens and children, they are likely most looking forward to the vaccine so that they may be able to get back to more normal social activities and gatherings with their friends, and so that they don't have to worry as much about parents and older relatives," said Stephanie Ewing, an assistant professor in counseling and at Drexel University's College of Nursing and Health Professions.

There also are concerns about the physical health of kids and teens. In the spring, the Centers for Disease Control and Prevention released a study that showed that routine vaccinations—and regular checkups—fell drastically in the first few months of the pandemic as stay-at-home orders were in place. In a report published November by Blue Cross Blue Shield Association, childhood vaccinations for measles and whooping cough fell 26% compared to 2019.

One silver lining of the pandemic has been a in cases of strep throat, flu, and ear infections, likely due to social distancing, said Jonathan Miller, a pediatrician in at Nemours/Alfred I. duPont Hospital for Children.

But, Miller said, he's also noticed "kids have been more inactive, doing a lot of screen time, and there's definitely concern about them being at home for prolonged periods of time and that impact on overall well-being."

Even more alarming: He's observed an increase in depressive and anxiety symptoms, as well as thoughts of suicide. Because of that, his practice has shifted to more proactive and preventative care when dealing with behavioral and mental health, he said.

"We're worried about them falling through the cracks," Miller said. "So we're trying to find new ways on telemedicine to give the family the ability to connect with us, and provide resources that can help them through troubling times."

Katie Lockwood, a pediatrician at the Children's Hospital of Philadelphia, said that while overall pediatric visits to the emergency room have gone down nationally in the past year, behavioral health visits increased, showing the negative impact of the pandemic on the mental health of children and adolescents.

"I want to make sure we have enough services to meet the behavioral health demands both in and outside of schools as kids start to go back to school," she said. "While anxiety related to school has been lower, I do worry about how kids who did well with virtual learning will be supported through the transition back to in-person learning."

Without in-person school, there has been a huge impact on the educational and social development of children and teens, said Ewing. The constant presence of anxiety and worry can impair learning, she said.

Many health experts are still unsure about what the pandemic's long-term consequences on pediatric and adolescent health will be. Ewing said that there's an opportunity to mitigate some of the effects on a community level by paying attention to health disparities resulting from differences in socioeconomic status and ethnic background and offering services to address them.

"If children are struggling with feelings of anxiety, irritability, boredom, and depressive symptoms—all natural by-products for everyone coping with the pandemic—are we as communities and as a society providing enough resources for a family to cope with those things? Are we enacting support for families so they can meet basic needs?" Ewing said. "Because if not, that's going to exacerbate the situation and make it more difficult for children to weather the storm."

Parental stress is one of the most important factors that can affect how a child is doing emotionally, Ewing said.

"When parents are stressed and don't have resources that they need to take care of their families or to help their children feel safe, it's going to impact the household," she said.

When kids' daily routines are disrupted, they may experience more anxiety than usual, leading to changes in their sleep and eating patterns, Ewing said. She said that anecdotally, children are staying up much later using their electronic devices. But blue light from devices can trick the body into thinking it's still daytime, making it harder to fall asleep. In the long term, that can be really damaging to a child's health, Ewing said.

"Changes in your sleep, meal times and exercise schedule can influence each other," Lockwood said. "There's more disrupted sleep, eating meals at different times and less physical activity. Kids are going to return to school eventually, and it takes a while for negative habits to reverse themselves."

Most pediatricians have been conducting patient visits over telehealth for the past year. There are a significant number of advantages that come with that, Miller said. He said that telemedicine, when used in conjunction with in-person care, can help provide pediatricians with an additional level of screening.

"We have to recognize that the parents of kids now are the ones who are going to expect telemedicine to be part of how they interact with the health care system in the future," Miller said. "We've tried to be really responsive to that. We've rolled out screenings looking for social determinants of health, like food insecurity, transportation issues and housing issues, and we try to provide resources and education to families that need them."

Lockwood also praised the flexibility of telemedicine. She said that it's now easier for pediatricians to connect with patients after school or over a lunch break, which is less disruptive to their learning. In general, she said pediatrics is becoming more creative about how to provide care.

"We've partnered with schools, nurses and teachers to manage testing and screen for symptoms," Lockwood said. "That partnership is hopefully one that we can carry forward."


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